Recent investigative reports in the New York Times and Washington Post delve into some of the profit-maximizing practices among healthcare providers that are can put patients’ lives at risk. Polls have found that people have high levels of trust in their doctors, but these pieces show how financial pressures and incentives can lead to decisions that aren’t in patients’ best interests.
Last week, Julie Creswell and Reed Abelson reported in the New York Times on hospital giant HCA, which was bought by private equity firms (including Bain Capital) in 2006 and has since generated impressive revenues. Cresswell and Abelson summarize how HCA has become such a financial powerhouse:
Among the secrets to HCA’s success: It figured out how to get more revenue from private insurance companies, patients and Medicare by billing much more aggressively for its services than ever before; it found ways to reduce emergency room overcrowding and expenses; and it experimented with new ways to reduce the cost of its medical staff, a move that sometimes led to conflicts with doctors and nurses over concerns about patient care.
Turning away patients not deemed as in need of emergency care has helped HCA reduce its emergency-department expenses, albeit at the price of putting some doctors in a moral quandary. Reductions in staffing costs have been accompanied by high rates of bedsores at several HCA facilities; because bedsores prevention involves regular and consistent attention from nurses, bedsore rates are often seen as an indicator of staffing-level quality.
Abelson and Cresswell reported earlier this month on another troubling aspect of care at some of HCA’s Florida hospitals: some doctors appear to be performing invasive cardiac procedures on patients who don’t need them. The article explains:
HCA, the largest for-profit hospital chain in the United States with 163 facilities, had uncovered evidence as far back as 2002 and as recently as late 2010 showing that some cardiologists at several of its hospitals in Florida were unable to justify many of the procedures they were performing. Those hospitals included the Cedars Medical Center in Miami, which the company no longer owns, and the Regional Medical Center Bayonet Point. In some cases, the doctors made misleading statements in medical records that made it appear the procedures were necessary, according to internal reports.
Questions about the necessity of medical procedures — especially in the realm of cardiology — are not uncommon. None of the internal documents reviewed calculate just how many such procedures there were or how many patients might have died or been injured as a result. But the documents suggest that the problems at HCA went beyond a rogue doctor or two.
At Lawnwood [Regional medical Center], where an invasive diagnostic test known as a cardiac catheterization is performed, about half the procedures, or 1,200, were determined to have been done on patients without significant heart disease, according to a confidential 2010 review. HCA countered recently with a different analysis, saying the percentage of patients without disease was much lower and in keeping with national averages.
Medicare reimbursements of around $10,000 per cardiac stent and $3,000 per diagnostic catheterization make these procedures reliable moneymakers — and HCA’s changing ownership situation has created a particular need for revenue. Private-equity firms took the company private in 2006, and by mid-2010 wanted to start cashing out on their investment, Abelson and Cresswell report. In preparation for its 2011 IPO, HCA borrowed to give $4.3 billion in dividends to the firms.
Peter Whoriskey’s recent Washington Post investigative piece “Anemia drugs made billions, but at what costs?” illustrates how profitable-but-dangerous medical practices can proliferate. Amgen and Johnson & Johnson presented unbalanced pictures of the risks and benefits of their anemia drugs – Epogen, Procrit, and Aransep, which generated more than $8 billion in sales annually – and pushed their use among an ever-widening patient population. Because the drugs are physician-administered, practices had an incentive to give them to many patients; drugmakers increased that incentive by giving bigger discounts to practices that engaged in high-volume dispensing. One expert told Whoriskey that an oncologist could make $100,000 – $300,000 annually just from dispensing anemia drugs. Whoriskey reports, “At the peak of the boom in 2007, more than 80 percent of 175,000 dialysis patients on Medicare were receiving the drug at levels beyond what the FDA now considers safe, according to federal statistics.”
Whoriskey highlights a couple of points at which FDA apparently could have slowed the proliferation of anemia-drug use in patients who turned out to risks in exchange for questionable benefits:
The trouble would arise as the drugmakers won FDA approval for vastly expanded uses, pushing it in larger doses, for milder anemia and for patients with a wider array of illnesses. Very quickly, the market included nearly all dialysis patients, not just the roughly 16 percent who required blood transfusions. The size of average doses would more than triple. And over the next five years, the FDA would approve it to treat anemia in patients with cancer and AIDS, as well as those getting hip and knee surgery.
The key to their marketing was the claim that the drugs at higher doses could make patients feel better. By 1994, the drug’s label, approved by the FDA, advertised a range of benefits: “statistically significant improvements for . . . health, sex life, well-being, psychological effect, life satisfaction, and happiness.”
Those claims, withdrawn 13 years later because they did not meet new FDA standards for proof, would be the basis of television and print advertising campaigns, pitched to people with potentially fatal illnesses.
The drugs, according to one, offered “Strength for Life.”
But while ads touted the drugs’ virtues, some at the FDA had raised safety concerns. To address them, the drugmakers agreed to conduct two key safety studies.
The first was supposed to evaluate the drug’s “safety profile” and enrolled 2,100 patients. Scientists affiliated with Amgen published “interim” results in 1991 and 1993.
But the full safety results of the study were never published, and in later lists of safety investigations by the FDA and Amgen, there appears to be no reference to this study.
It’s not clear from the agency’s records how seriously anyone was taking the results, anyway. Amgen filed a “clinical study report” with the agency in 1995, and the company says its research commitment was fulfilled then. But the FDA did not deem the study completed until March 2004, almost 15 years after the company agreed to conduct it.
Enthusiasm for profitable drugs and procedures can lead to inappropriate medical care. Our current system has safeguards at multiple levels — from individual hospitals to federal agencies — but, as these stories demonstrate, they’re not always enough. Investigative journalists who uncover these kinds of problems and bring them to the public’s attention also play an important role in our healthcare system.